Using ChatGPT-4 to Create Structured Medical Notes From Audio Recordings of Physician-Patient Encounters: Comparative Study.

BACKGROUND: Medical documentation plays a crucial role in clinical practice, facilitating accurate patient management and communication among health care professionals. However, inaccuracies in medical notes can lead to miscommunication and diagnostic errors. Additionally, the demands of documentation contribute to physician burnout. Although intermediaries like medical scribes and speech recognition software have been used to ease this burden, they have limitations in terms of accuracy and addressing provider-specific metrics. The integration of ambient artificial intelligence (AI)-powered solutions offers a promising way to improve documentation while fitting seamlessly into existing workflows. OBJECTIVE: This study aims to assess the accuracy and quality of Subjective, Objective, Assessment, and Plan (SOAP) notes generated by ChatGPT-4, an AI model, using established transcripts of History and Physical Examination as the gold standard. We seek to identify potential errors and evaluate the model's performance across different categories. METHODS: We conducted simulated patient-provider encounters representing various ambulatory specialties and transcribed the audio files. Key reportable elements were identified, and ChatGPT-4 was used to generate SOAP notes based on these transcripts. Three versions of each note were created and compared to the gold standard via chart review; errors generated from the comparison were categorized as omissions, incorrect information, or additions. We compared the accuracy of data elements across versions, transcript length, and data categories. Additionally, we assessed note quality using the Physician Documentation Quality Instrument (PDQI) scoring system. RESULTS: Although ChatGPT-4 consistently generated SOAP-style notes, there were, on average, 23.6 errors per clinical case, with errors of omission (86%) being the most common, followed by addition errors (10.5%) and inclusion of incorrect facts (3.2%). There was significant variance between replicates of the same case, with only 52.9% of data elements reported correctly across all 3 replicates. The accuracy of data elements varied across cases, with the highest accuracy observed in the "Objective" section. Consequently, the measure of note quality, assessed by PDQI, demonstrated intra- and intercase variance. Finally, the accuracy of ChatGPT-4 was inversely correlated to both the transcript length (P=.05) and the number of scorable data elements (P=.05). CONCLUSIONS: Our study reveals substantial variability in errors, accuracy, and note quality generated by ChatGPT-4. Errors were not limited to specific sections, and the inconsistency in error types across replicates complicated predictability. Transcript length and data complexity were inversely correlated with note accuracy, raising concerns about the model's effectiveness in handling complex medical cases. The quality and reliability of clinical notes produced by ChatGPT-4 do not meet the standards required for clinical use. Although AI holds promise in health care, caution should be exercised before widespread adoption. Further research is needed to address accuracy, variability, and potential errors. ChatGPT-4, while valuable in various applications, should not be considered a safe alternative to human-generated clinical documentation at this time.

How Providers Can Optimize Effective and Safe Scribe Use: a Qualitative Study.

BACKGROUND: The use of electronic health records has generated an increase in after-hours and weekend work for providers. To alleviate this situation, the hiring of medical scribes has rapidly increased. Given the lack of scribe industry standards and the wide variance in how providers and scribes work together, it could potentially create new patient safety-related risks. OBJECTIVE: The purpose of this paper was to identify how providers can optimize the effective and safe use of scribes. DESIGN: The research team conducted a secondary analysis of qualitative data where we reanalyzed data from interview transcripts, field notes, and transcribed group discussions generated by four previous projects related to medical scribes. PARTICIPANTS: Purposively selected participants included subject matter experts, providers, informaticians, medical scribes, medical assistants, administrators, social scientists, medical students, and qualitative researchers. APPROACH: The team used NVivo12 to assist with the qualitative analysis. We used a template method followed by word queries to identify an optimum level of scribe utilization. We then used an inductive interpretive theme-generation process. KEY RESULTS: We identified three themes: (1) communication aspects, (2) teamwork efforts, and (3) provider characteristics. Each theme contained specific practices so providers can use scribes safely and in a standardized way. CONCLUSION: We utilized a secondary qualitative data analysis methodology to develop themes describing how providers can optimize their use of scribes. This new knowledge could increase provider efficiency and safety and be incorporated into further and future training tools for them.

Disparities in Electronic Screening for Cancer-Related Psychosocial Distress May Promote Systemic Barriers to Quality Oncologic Care.

BACKGROUND: Screening for cancer-related psychosocial distress is an integral yet laborious component of quality oncologic care. Automated preappointment screening through online patient portals (Portal, MyChart) is efficient compared with paper-based screening, but unstudied. We hypothesized that patient access to and engagement with EHR-based screening would positively correlate with factors associated with digital literacy (eg, age, socioeconomic status). METHODS: Screening-eligible oncology patients seen at our Comprehensive Cancer Center from 2014 through 2019 were identified. Patients with active Portals were offered distress screening. Portal and screening participation were analyzed via multivariable logistic regression. Household income in US dollars and educational attainment were estimated utilizing zip code and census data. RESULTS: Of 17,982 patients, 10,279 (57%) had active Portals and were offered distress screening. On multivariable analysis, older age (odds ratio [OR], 0.97/year; P<.001); male gender (OR, 0.89; P<.001); Black (OR, 0.47; P<.001), Hawaiian/Pacific Islander (OR, 1.54; P=.007), and Native American/Alaskan Native race (OR, 0.67; P=.04); Hispanic ethnicity (OR, 0.76; P<.001); and Medicare (OR, 0.59; P<.001), Veteran's Affairs/military (OR, 0.09; P<.01), Medicaid (OR, 0.34; P<.001), or no insurance coverage (OR, 0.57; P<.001) were independently associated with lower odds of being offered distress screening; increasing income (OR, 1.05/$10,000; P<.001) and educational attainment (OR, 1.03/percent likelihood of bachelor's degree or higher; P<.001) were independently associated with higher odds. In patients offered electronic screening, participation rate was 36.6% (n=3,758). Higher educational attainment (OR, 1.01; P=.03) was independently associated with participation, whereas Black race (OR, 0.58; P=.004), Hispanic ethnicity (OR, 0.68; P=.01), non-English primary language (OR, 0.67; P=.03), and Medicaid insurance (OR, 0.78; P<.001) were independently associated with nonparticipation. CONCLUSIONS: Electronic portal-based screening for cancer-related psychosocial distress leads to underscreening of vulnerable populations. At institutions using electronic distress screening workflows, supplemental screening for patients unable or unwilling to engage with electronic screening is recommended to ensure efficient yet equal-opportunity distress screening.

The future of medical scribes documenting in the electronic health record: results of an expert consensus conference.

BACKGROUND: With the use of electronic health records (EHRs) increasing and causing unintended negative consequences, the medical scribe profession has burgeoned, but it has yet to be regulated. The purpose of this study was to describe scribe workflow as well as identify the threats and opportunities for the future of the scribe industry. METHODS: The first phase of the study used ethnographic methods consisting of interviews and observations by a multi-disciplinary team of researchers at five United States sites. In April 2019, a two-day conference of experts representing different stakeholder perspectives was held to discuss the results from site visits and to predict the future of medical scribing. An interpretive content analysis approach was used to discover threats and opportunities for the future of medical scribes. RESULTS: Threats facing the medical scribe industry were related to changes in the documentation model, EHR usability, different payment structures, the need to acquire disparate data during clinical encounters, and workforce-related changes relevant to the scribing model. Simultaneously, opportunities for medical scribing in the future included extension of their role to include workflow analysis, acting as EHR-related subject-matter-experts, and becoming integrated more effectively into the clinical care delivery team. Experts thought that if EHR usability increases, the need for medical scribes might decrease. Additionally, the scribe role could be expanded to allow scribes to document more or take on more informatics-related tasks. The experts also anticipated an increased use of alternative models of scribing, like tele-scribing. CONCLUSION: Threats and opportunities for medical scribing were identified. Many experts thought that if the scribe role could be expanded to allow scribes to document more or take on more informatics activities, it would be beneficial. With COVID-19 continuing to change workflows, it is critical that medical scribes receive standardized training as tele-scribing continues to grow in popularity and new roles for scribes as medical team members are identified.

Data Omission by Physician Trainees on ICU Rounds.

OBJECTIVES: Incomplete patient data, either due to difficulty gathering and synthesizing or inappropriate data filtering, can lead clinicians to misdiagnosis and medical error. How completely ICU interprofessional rounding teams appraise the patient data set that informs clinical decision-making is unknown. This study measures how frequently physician trainees omit data from prerounding notes ("artifacts") and verbal presentations during daily rounds. DESIGN: Observational study. SETTING: Tertiary academic medical ICU with an established electronic health record and where physician trainees are the primary presenters during daily rounds. SUBJECTS: Presenters (medical student or resident physician), interprofessional rounding team. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We quantified the amount and types of patient data omitted from photocopies of physician trainees' artifacts and audio recordings of oral ICU rounds presentations when compared with source electronic health record data. An audit of 157 patient presentations including 6,055 data elements across nine domains revealed 100% of presentations contained omissions. Overall, 22.9% of data were missing from artifacts and 42.4% from presentations. The interprofessional team supplemented only 4.1% of additional available data. Frequency of trainee data omission varied by data type and sociotechnical factors. The strongest predictor of trainee verbal omissions was a preceding failure to include the data on the artifact. Passive data gathering via electronic health record macros resulted in extremely complete artifacts but paradoxically predicted greater likelihood of verbal omission when compared with manual notation. Interns verbally omitted the most data, whereas medical students omitted the least. CONCLUSIONS: In an academic rounding model reliant on trainees to preview and select data for presentation during ICU rounds, verbal appraisal of patient data was highly incomplete. Additional trainee oversight and education, improved electronic health record tools, and novel academic rounding paradigms are needed to address this potential source of medical error.

Use of a Novel, Electronic Health Record-Centered, Interprofessional ICU Rounding Simulation to Understand Latent Safety Issues.

OBJECTIVES: The electronic health record is a primary source of information for all professional groups participating in ICU rounds. We previously demonstrated that, individually, all professional groups involved in rounds have significant blind spots in recognition of patient safety issues in the electronic health record. However, it is unclear how team dynamics impacts identification and verbalization of viewed data. Therefore, we created an ICU rounding simulation to assess how the interprofessional team recognized and reported data and its impact on decision-making. DESIGN: Each member of the ICU team reviewed a simulated ICU chart in the electronic health record which contained embedded patient safety issues. The team conducted simulated rounds according to the ICU's existing rounding script and was assessed for recognition of safety issues. SETTING: Academic medical center. SUBJECTS: ICU residents, nurses, and pharmacists. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Twenty-eight teams recognized 68.6% of safety issues with only 50% teams having the primary diagnosis in their differential. Individually, interns, nurses, and pharmacists recognized 30.4%, 15.6%, and 19.6% of safety items, respectively. However, there was a negative correlation between the intern's performance and the nurse's or the pharmacist's performance within a given team. The wide variance in recognition of data resulted in wide variance in orders. Overall, there were 21.8 orders requested and 21.6 orders placed per case resulting in 3.6 order entry inconsistencies/case. Between the two cases, there were 145 distinct orders place with 43% being unique to a specific team and only 2% placed by all teams. CONCLUSIONS: Although significant blind spots exist in the interprofessional team's ability to recognize safety issues in the electronic health record, the inclusion of other professional groups does serve as a partial safety net to improve recognition. Electronic health record-based, ICU rounding simulations can serve as a test-bed for innovations in ICU rounding structure and data collection.

Chirp-Evoked Otoacoustic Emissions and Middle Ear Absorbance for Monitoring Ototoxicity in Cystic Fibrosis Patients.

OBJECTIVES: The goal of this study was to investigate the use of transient-evoked otoacoustic emissions (TEOAEs) and middle ear absorbance measurements to monitor auditory function in patients with cystic fibrosis (CF) receiving ototoxic medications. TEOAEs were elicited with a chirp stimulus using an extended bandwidth (0.71 to 8 kHz) to measure cochlear function at higher frequencies than traditional TEOAEs. Absorbance over a wide bandwidth (0.25 to 8 kHz) provides information on middle ear function. The combination of these time-efficient measurements has the potential to identify early signs of ototoxic hearing loss. DESIGN: A longitudinal study design was used to monitor the hearing of 91 patients with CF (median age = 25 years; age range = 15 to 63 years) who received known ototoxic medications (e.g., tobramycin) to prevent or treat bacterial lung infections. Results were compared to 37 normally hearing young adults (median age = 32.5 years; age range = 18 to 65 years) without a history of CF or similar treatments. Clinical testing included 226-Hz tympanometry, pure-tone air-conduction threshold testing from 0.25 to 16 kHz and bone conduction from 0.25 to 4 kHz. Experimental testing included wideband absorbance at ambient and tympanometric peak pressure and TEOAEs in three stimulus conditions: at ambient pressure and at tympanometric peak pressure using a chirp stimulus with constant incident pressure level across frequency and at ambient pressure using a chirp stimulus with constant absorbed sound power across frequency. RESULTS: At the initial visit, behavioral audiometric results indicated that 76 of the 157 ears (48%) from patients with CF had normal hearing, whereas 81 of these ears (52%) had sensorineural hearing loss for at least one frequency. Seven ears from four patients had a confirmed behavioral change in hearing threshold for ≥3 visits during study participation. Receiver operating characteristic curve analyses demonstrated that all three TEOAE conditions were useful for distinguishing CF ears with normal hearing from ears with sensorineural hearing loss, with an area under the receiver operating characteristic curve values ranging from 0.78 to 0.92 across methods for frequency bands from 2.8 to 8 kHz. Case studies are presented to illustrate the relationship between changes in audiometric thresholds, TEOAEs, and absorbance across study visits. Absorbance measures permitted identification of potential middle ear dysfunction at 5.7 kHz in an ear that exhibited a temporary hearing loss. CONCLUSIONS: The joint use of TEOAEs and absorbance has the potential to explain fluctuations in audiometric thresholds due to changes in cochlear function, middle ear function, or both. These findings are encouraging for the joint use of TEOAE and wideband absorbance objective tests for monitoring ototoxicity, particularly, in patients who may be too ill for behavioral hearing tests. Additional longitudinal studies are needed in a larger number of CF patients receiving ototoxic drugs to further evaluate the clinical utility of these measures in an ototoxic monitoring program.

Accuracy of Laboratory Data Communication on ICU Daily Rounds Using an Electronic Health Record.

OBJECTIVES: Accurately communicating patient data during daily ICU rounds is critically important since data provide the basis for clinical decision making. Despite its importance, high fidelity data communication during interprofessional ICU rounds is assumed, yet unproven. We created a robust but simple methodology to measure the prevalence of inaccurately communicated (misrepresented) data and to characterize data communication failures by type. We also assessed how commonly the rounding team detected data misrepresentation and whether data communication was impacted by environmental, human, and workflow factors. DESIGN: Direct observation of verbalized laboratory data during daily ICU rounds compared with data within the electronic health record and on presenters' paper prerounding notes. SETTING: Twenty-six-bed academic medical ICU with a well-established electronic health record. SUBJECTS: ICU rounds presenter (medical student or resident physician), interprofessional rounding team. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During 301 observed patient presentations including 4,945 audited laboratory results, presenters used a paper prerounding tool for 94.3% of presentations but tools contained only 78% of available electronic health record laboratory data. Ninty-six percent of patient presentations included at least one laboratory misrepresentation (mean, 6.3 per patient) and 38.9% of all audited laboratory data were inaccurately communicated. Most misrepresentation events were omissions. Only 7.8% of all laboratory misrepresentations were detected. CONCLUSION: Despite a structured interprofessional rounding script and a well-established electronic health record, clinician laboratory data retrieval and communication during ICU rounds at our institution was poor, prone to omissions and inaccuracies, yet largely unrecognized by the rounding team. This highlights an important patient safety issue that is likely widely prevalent, yet underrecognized.

Medical Record Closure Practices of Physicians Before and After the Use of Medical Scribes.

This study uses electronic health record data to evaluate medical record closure outcomes before and after the use of medical scribes at a large academic medical center.

Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients.

During interprofessional intensive care unit (ICU) rounds each member of the interprofessional team is responsible for gathering and interpreting information from the electronic health records (EHR) to facilitate effective team decision-making. This study was conducted to determine how each professional group reviews EHR data in preparation for rounds and their ability to identify patient safety issues. Twenty-five physicians, 29 nurses, and 20 pharmacists participated. Individual participants were given verbal and written sign-out and then asked to review a simulated record in our institution's EHR, which contained 14 patient safety items. After reviewing the chart, subjects presented the patient and the number of safety items recognised was recorded. About 40%, 30%, and 26% of safety issues were recognised by physicians, nurses, and pharmacists, respectively (p = 0.0006) and no item recognised 100% of the time. There was little overlap between the three groups with only 50% of items predicted to be recognised 100% of the time by the team. Differential recognition was associated with marked differences in EHR use, with only 3/152 EHR screens utilised by all three groups and the majority of screens used exclusively only by one group. There were significant and non-overlapping differences in individual profession recognition of patient safety issues in the EHR. Preferential identification of safety issues by certain professional groups may be attributed to differences in EHR use. Future studies will be needed to determine if shared decision-making during rounds can improve recognition of safety issues.

Integrating the Electronic Health Record into high-fidelity interprofessional intensive care unit simulations.

With the rapid adoption of electronic health records (EHR), there is a growing appreciation for the central role they play in clinical decision making and team communication, with many studies documenting new safety issues with integration of the EHR into the clinical enterprise. To study these issues, we created a high-fidelity simulation instance of our clinical EHR. In this paper, we describe the impact of integrating the EHR into high-fidelity, interprofessional intensive care unit (ICU) simulations, and the errors induced. We found a number of safety issues directly related to the EHR including alert fatigue, negative impacts on interprofessional communication, and problems with selective data gathering, and these issues were present for all members of the interprofessional team. Through successful integration of the EHR into high-fidelity team-based simulations, we now have an infrastructure to focus educational initiative and deploy informatics solutions to mitigate these safety issues.

Participation in EHR based simulation improves recognition of patient safety issues.

BACKGROUND: Electronic health records (EHR) are becoming increasingly integrated into the clinical environment. With the rapid proliferation of EHRs, a number of studies document an increase in adverse patient safety issues due to the EHR-user interface. Because of these issues, greater attention has been placed on novel educational activities which incorporate use of the EHR. The ICU environment presents many challenges to integrating an EHR given the vast amounts of data recorded each day, which must be interpreted to deliver safe and effective care. We have used a novel EHR based simulation exercise to demonstrate that everyday users fail to recognize a majority of patient safety issues in the ICU. We now sought to determine whether participation in the simulation improves recognition of said issues. METHODS: Two ICU cases were created in our EHR simulation environment. Each case contained 14 safety issues, which differed in content but shared common themes. Residents were given 10 minutes to review a case followed by a presentation of management changes. Participants were given an immediate debriefing regarding missed issues and strategies for data gathering in the EHR. Repeated testing was performed in a cohort of subjects with the other case at least 1 week later. RESULTS: 116 subjects have been enrolled with 25 subjects undergoing repeat testing. There was no difference between cases in recognition of patient safety issues (39.5% vs. 39.4%). Baseline performance for subjects who participated in repeat testing was no different than the cohort as a whole. For both cases, recognition of safety issues was significantly higher among repeat participants compared to first time participants. Further, individual performance improved from 39.9% to 63.6% (p = 0.0002), a result independent of the order in which the cases were employed. The degree of improvement was inversely related to baseline performance. Further, repeat participants demonstrated a higher rate of recognition of changes in vitals, misdosing of antibiotics and oversedation compared to first time participants. CONCLUSION: Participation in EHR simulation improves EHR use and identification of patient safety issues.

A Train-the-Trainer Simulation Program Implemented Between Two International Partners.

With the expansion of global health initiatives focused on healthcare professional training, it is important to ensure that such training is scalable and sustainable. Simulation-based education (SBE) is a highly effective means to achieve these goals. Although SBE is widely used in the United States, its integration globally is limited, which can impact the potential of SBE in many countries. The purpose of this perspective piece is to demonstrate how a train-the-trainer program can help in the development of an international SBE program and specifically what unique issues must be considered in operationalizing this strategy.

Variable Impact of Medical Scribes on Physician Electronic Health Record Documentation Practices: A Quantitative Analysis Across a Large, Integrated Health-System.

BACKGROUND: Medical scribes have been utilized to reduce electronic health record (EHR) associated documentation burden. Although evidence suggests benefits to scribes, no large-scale studies have quantitatively evaluated scribe impact on physician documentation across clinical settings. This study aimed to evaluate the effect of scribes on physician EHR documentation behaviors and performance. METHODS: This retrospective cohort study used EHR audit log data from a large academic health system to evaluate clinical documentation for all ambulatory encounters between January 2014 and December 2019 to evaluate the effect of scribes on physician documentation behaviors. Scribe services were provided on a first-come, first-served basis on physician request. Based on a physician's scribe use, encounters were grouped into 3 categories: never using a scribe, prescribe (before scribe use), or using a scribe. Outcomes included chart closure time, the proportion of delinquent charts, and charts closed after-hours. RESULTS: Three hundred ninety-five physicians (23% scribe users) across 29 medical subspecialties, encompassing 1,132,487 encounters, were included in the analysis. At baseline, scribe users had higher chart closure time, delinquent charts, and after-hours documentation than physicians who never used scribes. Among scribe users, the difference in outcome measures postscribe compared with baseline varied, and using a scribe rarely resulted in outcome measures approaching a range similar to the performance levels of nonusing physicians. In addition, there was variability in outcome measures across medical specialties and within similar subspecialties. CONCLUSION: Although scribes may improve documentation efficiency among some physicians, not all will improve EHR-related documentation practices. Different strategies may help to optimize documentation behaviors of physician-scribe dyads and maximize outcomes of scribe implementation.

Interleukin 5 is protective during sepsis in an eosinophil-independent manner.

RATIONALE: The immune response in sepsis is characterized by overt immune dysfunction. Studies indicate immunostimulation represents a viable therapy for patients. One study suggests a potentially protective role for interleukin 5 (IL-5) in sepsis; however, the loss of eosinophils in this disease presents a paradox. OBJECTIVES: To assess the protective and eosinophil-independent effects of IL-5 in sepsis. METHODS: We assessed the effects of IL-5 administration on survival, bacterial burden, and cytokine production after polymicrobial sepsis. In addition, we examined the effects on macrophage phagocytosis and survival using fluorescence microscopy and flow cytometry. MEASUREMENTS AND MAIN RESULTS: Loss of IL-5 increased mortality and tissue damage in the lung, IL-6 and IL-10 production, and bacterial burden during sepsis. Therapeutic administration of IL-5 improved mortality in sepsis. Interestingly, IL-5 administration resulted in neutrophil recruitment in vivo. IL-5 overexpression in the absence of eosinophils resulted in decreased mortality from sepsis and increased circulating neutrophils and monocytes, suggesting their importance in the protective effects of IL-5. Furthermore, novel data demonstrate IL-5 receptor expression on neutrophils and monocytes in sepsis. IL-5 augmented cytokine secretion, activation, phagocytosis, and survival of macrophages. Importantly, macrophage depletion before the onset of sepsis eliminated IL-5-mediated protection. The protective effects of IL-5 were confirmed in humans, where IL-5 levels were elevated in patients with sepsis. Moreover, neutrophils and monocytes from patients expressed the IL-5 receptor. CONCLUSIONS: Taken together, these data support a novel role for IL-5 on noneosinophilic myeloid populations, and suggest treatment with IL-5 may be a viable therapy for sepsis.

Electronic Health Record Use Issues and Diagnostic Error: A Scoping Review and Framework.

BACKGROUND: Diagnostic errors are a major source of patient harm, most of which are caused by cognitive errors and biases. Despite research showing the relationship between software systems and cognitive processes, the impact of the electronic health record (EHR) on diagnostic error remains unknown. METHODS: We conducted a scoping review of the scientific literature to (1) survey the association between aspects of the EHR and diagnostic error, and (2) through a human-systems integration lens, identify the types of EHR issues and their impact on the stages of the diagnostic process. RESULTS: We analyzed 11 research articles for the relationship between EHR use and diagnostic error. These articles highlight specific technical, usability, and workflow issues with the EHR that pose risks for diagnostic error at every stage of the diagnostic process. DISCUSSION: Although technical problems such as EHR interoperability and data integrity pose critical issues for the diagnostic process, usability and workflow issues such as poor display design, and inability to track test results also hamper clinicians' ability to track, process, and act in the diagnostic process. Current research methods have limited coverage over clinical settings, are not standardized, and rarely include measures of patient harm. CONCLUSIONS: The available evidence shows that EHRs pose risks for diagnostic error throughout the diagnostic process, with most issues involving their incompatibility with providers' cognitive processing. A structured and systematic model of collecting and reporting on these errors is needed to understand how the EHR shapes the diagnostic process and improve diagnostic accuracy.

The role of cyclooxygenase-2 in mechanical ventilation-induced lung injury.

Mechanical ventilation is necessary for patients with acute respiratory failure, but can cause or propagate lung injury. We previously identified cyclooxygenase-2 as a candidate gene in mechanical ventilation-induced lung injury. Our objective was to determine the role of cyclooxygenase-2 in mechanical ventilation-induced lung injury and the effects of cyclooxygenase-2 inhibition on lung inflammation and barrier disruption. Mice were mechanically ventilated at low and high tidal volumes, in the presence or absence of pharmacologic cyclooxygenase-2-specific inhibition with 3-(4-methylsulphonylphenyl)-4-phenyl-5-trifluoromethylisoxazole (CAY10404). Lung injury was assessed using markers of alveolar-capillary leakage and lung inflammation. Cyclooxygenase-2 expression and activity were measured by Western blotting, real-time PCR, and lung/plasma prostanoid analysis, and tissue sections were analyzed for cyclooxygenase-2 staining by immunohistochemistry. High tidal volume ventilation induced lung injury, significantly increasing both lung leakage and lung inflammation relative to control and low tidal volume ventilation. High tidal volume mechanical ventilation significantly induced cyclooxygenase-2 expression and activity, both in the lungs and systemically, compared with control mice and low tidal volume mice. The immunohistochemical analysis of lung sections localized cyclooxygenase-2 expression to monocytes and macrophages in the alveoli. The pharmacologic inhibition of cyclooxygenase-2 with CAY10404 significantly decreased cyclooxygenase activity and attenuated lung injury in mice ventilated at high tidal volume, attenuating barrier disruption, tissue inflammation, and inflammatory cell signaling. This study demonstrates the induction of cyclooxygenase-2 by mechanical ventilation, and suggests that the therapeutic inhibition of cyclooxygenase-2 may attenuate ventilator-induced acute lung injury.

OX40 ligand regulates inflammation and mortality in the innate immune response to sepsis.

The initial phase of sepsis is characterized by massive inflammatory cytokine production that contributes to multisystem organ failure and death. Costimulatory molecules are a class of receptors capable of regulating cytokine production in adaptive immunity. Recent studies described their presence on neutrophils and monocytes, suggesting a potential role in the regulation of cytokine production in innate immunity. The purpose of this study was to determine the role for OX40-OX40 ligand (OX40L) interaction in the innate immune response to polymicrobial sepsis. Humans with sepsis demonstrated upregulation of OX40L on monocytes and neutrophils, with mortality and intensive care unit stay correlating with expression levels. In an animal model of polymicrobial sepsis, a direct role for OX40L in regulating inflammation was indicated by improved survival, decreased cytokine production, and a decrease in remote organ damage in OX40L(-/-) mice. The finding of similar results with an OX40L Ab suggests a potential therapeutic role for OX40L blockade in sepsis. The inability of anti-OX40L to provide significant protection in macrophage-depleted mice establishes macrophages as an indispensable cell type within the OX40/OX40L axis that helps to mediate the clinical signs of disease in sepsis. Conversely, the protective effect of anti-OX40L Ab in RAG1(-/-) mice further confirms a T cell-independent role for OX40L stimulation in sepsis. In conclusion, our data provide an in vivo role for the OX40/OX40L system in the innate immune response during polymicrobial sepsis and suggests a potential beneficial role for therapeutic blockade of OX40L in this devastating disorder.

Just-in-Time Electronic Health Record Retraining to Support Clinician Redeployment during the COVID-19 Surge.

BACKGROUND: In response to surges in demand for intensive care unit (ICU) care related to the COVID-19 pandemic, health care systems have had to increase hospital capacity. One institution redeployed certified registered nurse anesthetists (CRNAs) as ICU clinicians, which necessitated training in ICU-specific electronic health record (EHR) workflows prior to redeployment. Under time- and resource-constrained settings, clinical informatics (CI) fellows could effectively be lead instructors for such training. OBJECTIVE: This study aimed to deploy CI fellows as lead EHR instructional trainers for clinician redeployment as part of an organization's response to disaster management. METHODS: CI fellows led a multidisciplinary team alongside subject matter experts to develop and deploy a tailored EHR curriculum comprising in-person classes and online video modules, leveraging high-fidelity simulated patient cases. The participants completed surveys immediately after the in-person training session and after deployment. RESULTS: Eighteen CRNAs participated, with 15 completing the postactivity survey (83%). All felt the training was useful and improved their EHR skills with a Net Promoter score of +87. Most (93%) respondents indicated the pace of the session was "just right," and 100% felt the clarity of instruction was "just right" or "extremely easy" to understand. Twelve participants (67%) completed the postdeployment survey. The training increased comfort in the ICU for all respondents, and 91% felt the training prepared them to work in the ICU with minimal guidance. All stated that the concepts learned would be useful in their anesthesia role. Fifty-eight percent viewed the online video library. CONCLUSION: This case report demonstrates that CI fellows with dual domain expertise in their clinical specialty and informatics are uniquely poised to deliver clinician redeployment EHR training in response to operational crises. Such opportunities can achieve fellowship educational goals while conserving physician resources which can be a strategic option as organizations plan for disaster management.

Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach.

OBJECTIVE: While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training. MATERIALS AND METHODS: A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team's analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists. RESULTS: The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired. CONCLUSION: We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.